Eme S Ufomba
Profession: Occupational therapist
Registration Number: OT53882
Hearing Type: Review Hearing
Date and Time of hearing: 10:00 12/08/2024
End:
17:00 12/08/2024
Location:
Virtually via video conference.
Panel: Conduct and Competence Committee
Outcome: Conditions of Practice
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Allegation
(As amended on day 1 of the hearing, namely, 17 July 2023)
As a registered Occupational Therapist (OT53882) your fitness to practise is impaired by reason of misconduct. In that:
1. On 29 July 2020, during a home visit to Service User 1, you did not provide adequate care in that you:
a. did not recognise Service User 1’s presenting need for medical
assessment and/or treatment,
b. left Service User 1 at home and unattended when they required or appeared to require medical assessment and/or treatment,
c. did not call for an ambulance,
d. did not alert any healthcare professionals to inform them of Service User 1’s presenting condition.
2. On 29 July 2020, your actions outlined in particular 1 above caused delay to Service User 1 receiving medical treatment.
3. Between 28 July 2020 and 29 July 2020, you did not maintain complete and accurate records of your visits to Service User 1 at their home address, in that you:
a. You did not document any clinical rationale for why you did not seek medical attention.
4. The matters set out in particulars 1, 2 and 3 above constitute misconduct.
5. By reason of your misconduct your fitness to practise is impaired.
Finding
Preliminary Matters
Application to conduct part of the hearing in private
1. Mr Walker applied for part of the hearing to be conducted in private in order to protect the private life of the Registrant. He submitted that there would be references to health matters, including the health of a family member, during the review hearing. Ms Khorassani supported Mr Walker’s submission.
2. The Panel has considered Mr Walker’s submissions. It has also had regard to the HCPTS Practice Note on Conducting Hearings in Private, and it has received and accepted legal advice. The Panel is aware that these proceedings should be conducted in public unless there is a compelling reason for either the whole or part of the hearing to be held in private.
3. With regard to the matters relating to either the Registrant’s health or the health of a family member, the Panel directs that these should be heard in private in order to protect her private life.
Background
4. The Registrant is an Occupational Therapist (“OT”) who was employed as a Band 6 OT within the rapid response team at Virgin Care between 23 March 2020 and 4 December 2020.
5. On 29 July 2020, the Registrant attended Service User 1’s home address. Social Services had requested that the Registrant undertake a functional assessment of Service User 1. Upon arrival, Service User 1 was unwell and was bleeding heavily from her lower body. The Registrant cleaned Service User 1, changed the blood-soaked bed mats and then left the property. The Registrant informed Social Services of Service User 1’s condition but did not contact emergency services.
6. Later that morning, carers from Austen Allen Agency arrived at Service User 1’s home. The carers found Service User 1 in a very poor condition and proceeded to call the emergency services.
7. Service User 1’s daughter made a formal complaint to Virgin Care regarding the care that was provided by the Registrant to Service User 1. As a result of the complaint, an internal investigation was conducted.
8. On 5 August 2020, Virgin Care made a fitness to practise referral to the HCPC.
9. On 19 October 2021, a panel of the HCPC’s Investigating Committee found that there was a case for the Registrant to answer and referred the matter to the Conduct and Competence Committee.
The Substantive Hearing
10. A panel of the Conduct and Competence Committee heard the case between 17 and 21 July 2023. It found all the particulars of the Allegation and the ground of misconduct proved. The panel found the Registrant’s fitness to practice to be impaired and imposed a 12-month Suspension Order.
11. The panel heard evidence from three witnesses called by the HCPC and also received a bundle of evidence from the HCPC which totalled 200 pages. It heard evidence from the Registrant and considered two bundles of evidence produced on her behalf (totalling 332 and 31 pages), as well as the Registrant’s witness statement.
12. The panel found all the particulars of the Allegation proved, and it was satisfied that the concerns were serious in nature and amounted to misconduct. The panel indicated that the Registrant’s conduct was in breach of standards 3.2, 6.1, 6.2, 7.1, 7.3, 10.1 and 10.2 of the HCPC’s Standards of Conduct, Performance and Ethics 2016. The panel was satisfied that the Registrant had failed to deal with the situation presented to her and failed to undertake a risk assessment. It concluded that the Registrant’s actions and omissions fell short of what would be proper in the circumstances.
13. In relation to impairment and the personal component, the panel found that the misconduct was remediable. It considered that as there was only extremely limited evidence of insight or remediation by the Registrant, that there was a high risk of her repeating the misconduct. The panel was concerned that the Registrant had continued to advance a case which was not supported by the evidence and was unable to acknowledge the findings of the panel in her representations to them regarding impairment. The panel noted that the Registrant continued to apportion blame in relation to the situation upon others and that she was unable to take responsibility for her own acts/omissions. It concluded that until the Registrant was able to acknowledge and address the actions which led to the misconduct there was an increased risk of repetition.
14. The panel acknowledged that the incident on 29 July 2020 was a one-off incident and that it had not been intentional, but it indicated its concern that the Registrant’s reflections related primarily to the impact of the situation upon herself rather than the safety of service users. The panel noted that the Registrant had completed some online learning in relation to first aid, safeguarding vulnerable adults and emergency resuscitation. However, the panel was satisfied that despite this, the Registrant had yet to acknowledge that there was a delay in Service User 1 receiving medical assessment and/or treatment, or that her conduct fell below professional standards. The Registrant had shown no understanding of the potential consequences of her actions on Service User 1 and had failed to acknowledge the impact on the wider reputation of the profession. The panel therefore found that there was a risk of harm to service users due to the reckless disregard of risk demonstrated by the Registrant on 29 July 2020 and that the Registrant’s fitness to practise was impaired on the personal component.
15. In relation to the public component, the panel concluded that the public would be dismayed if there was no finding of impairment following misconduct of the type proved. It found the Registrant’s fitness to practise impaired on the public component, having decided that such a finding was required in order to ensure that the public has confidence in the profession and its regulator. The panel referred to the Standards of Conduct, Performance and Ethics which it had found the Registrant to have breached and found that these were fundamental tenets of the OT profession which had brought the profession into disrepute.
16. The panel found the following mitigating factors:
• The timing of the incident which was in the midst of the Covid-19 pandemic, was highly relevant and it would have presented additional challenges to an already struggling health and social care system;
• That it was a one-off incident, and that the Registrant had no regulatory history;
• That the Registrant had shown some care and compassion in dealing with Service User 1;
• That the Registrant had engaged in the regulatory process and had attended the hearing.
17. The panel found the following aggravating factors:
• The Registrant’s lack of insight which led to there being a high risk of repetition; while the Registrant had shown some care and compassion towards Service User 1, this had been misdirected and had not focused on her immediate medical needs. The Registrant had also failed to demonstrate that she had considered Service User 1’s wishes and feelings and responded accordingly. The Registrant had failed to recognise that she may have made Service User 1’s condition worse by both moving her and delaying her medical assessment and/or treatment.
• That the Registrant’s reflections and how she would deal with a similar situation in the future appeared more to protect herself from future regulatory investigation that out of concern for the safety of service users.
• That the Registrant had been less than open and honest in her account to the Panel which was not in accordance with the duty of candour required of health care professionals.
• The lack of steps taken to remedy her deficiencies and there was no evidence that the Registrant had made changes to her practice as a result of any lessons learned or as a result of the online training which she had undertaken.
18. The panel decided that the appropriate and proportionate sanction was a 12-month Suspension Order. It had concluded that any conditions of practice it could formulate which were sufficient to address the risks it had identified were tantamount to a suspension. It also concluded that an order striking the Registrant from the Register would be disproportionate in this case. The panel considered that the incident had been a one-off incident which had been reckless rather than deliberate at a time when the Registrant had been clearly distressed by the situation she was presented with. The panel decided that the Registrant should be afforded the opportunity to develop appropriate insight.
19. The panel also considered that this Panel might be assisted by the following:
• Details of how the knowledge gained by the Registrant from courses; such as first aid, safeguarding vulnerable adults and emergency resuscitation has been transferred to her clinical practice.
• A reflective piece regarding the Panel’s findings, what went wrong in this case with regards to harm/potential harm caused to Service User 1, the impact of her acts/omissions on the profession and its regulation, and how the Registrant will change her future practices as a result.
• Evidence of understanding the requirement for and practice of keeping robust records which clearly outline the clinical rationale for any decisions made by the Registrant.
• Evidence of understanding the requirement for and practice of undertaking robust risk assessments.
• A case study of how the Registrant has effectively worked in partnership with other health professionals.
• The provision of up to date character references/testimonials about the Registrant.
Decision
20. This Panel reviewed the HCPC bundle which totalled 33 pages and included the original panel’s determination. The Panel considered the Registrant’s evidence and also reviewed documentation provided by her which totalled five pages and included an undated testimonial.
21. The Panel took account of the HCPTS’s Practice Notes “Review of Article 30 Sanction Orders” and “Fitness to Practise Impairment” and considered the submissions of both parties. The Panel received and accepted legal advice.
Registrant’s evidence
22. The Registrant gave evidence. She told the Panel that she accepted the original panel’s finding that as a healthcare professional, she should have acted upon the blood loss she had observed by either calling immediately for an ambulance or by contacting a colleague for advice. The Registrant accepted that she owed a duty of care to Service User 1 and that she had not recognised that there had been a need for medical assessment and/or treatment in the circumstances she had faced on 29 July 2020. The Registrant accepted that she had not provided adequate care and that her actions had caused a delay in Service User 1 receiving the medical treatment which she required.
23. The Registrant also accepted that her clinical notes had been inadequate and incomplete and that she had not recorded any clinical reasoning.
24. The Registrant told the Panel that she now accepted that her behaviour had fallen below the standards required of an occupational therapist.
25. The Registrant referred to the training she had received in first aid, safeguarding vulnerable adults and in emergency resuscitation. She explained that the first document in her bundle was her reflections on the fitness to practise concerns set out in the original panel’s determination and what she had learned from the courses she had undertaken. The Registrant told the Panel that she had learned a lot and in future would respond properly and effectively to medical emergencies to ensure that no harm would come to a patient. She explained that she would now always have the contact details of a number of more senior colleagues so that she could contact them for advice should she need it. The Registrant said that she would record every piece of information in the patient’s case notes so that there would be no doubts about what she had or had not done. The Registrant explained that she had looked online and was aware of the SOAP (Subjective, Objective, Assessment, Plan) approach to case notes. She said that she had reflected on this during the year of her suspension and felt she was wiser now.
26. The Registrant said that the impact of failing to respond promptly and effectively in a situation such as that which she had encountered with Service User 1, was that serious harm could have been caused to a patient and that public confidence in occupational therapists could be lost. She also said that such behaviour would not “look good” on the HCPC.
27. Referring to documents in her bundle, the Registrant indicated the importance of recording all information. She also said that it was important so that she would “not get into what I have got into”. The Registrant explained that the screenshots in her bundle were of a video regarding preparation of case notes which she had viewed and from which she had learned the importance of documenting e.g., medication given for purposes of continuity of care.
28. The Registrant stated that she had not worked as an occupational therapist because of her suspension and that after the experience of these proceedings, she would not get into trouble again as “it sticks in my mind”.
29. [Redacted].
30. The Registrant referred to a case where she had worked with others as part of a team. This had been in a rehabilitation setting where she had worked with others towards a service user’s discharge. She also referred to working with carers.
31. The Registrant said that she was going to reflect on going back to unrestricted practice. She confirmed that her referee was aware of why she had been suspended from work as an occupational therapist.
32. In cross examination, the Registrant told the Panel that she had been an occupational therapist for over 13 years. She described herself as a very compassionate person who loved caring for people, making them happy and supporting them. She had not taken any paid or unpaid work during the period of her suspension. The Registrant reiterated that her behaviour could have caused harm, brought her profession into disrepute and that it did not look good on the HCPC. She also said that her behaviour would have impacted on Service User 1’s family.
33. The Registrant said that when she had been working as an occupational therapist, she had been working five days a week and would normally be working autonomously unless two people were needed to undertake e.g., a hoist transfer.
34. The Registrant indicated that if she found herself in a similar situation, she would call for an ambulance immediately and would have contact numbers for more senior colleagues to consult. She considered that other occupational therapists would be her support system. The Registrant did not consider that her fitness to practise was currently impaired as she had had a year in which to reflect on what had happened. She felt that she was ready to return to unrestricted practice as the incident had been a one-off. However, were she required to comply with conditions on her practice, she would do so.
35. In answer to Panel questions, the Registrant indicated that prior to working for Virgin Care, post qualification she had worked in Social Services for about a year. She had worked as an occupational therapist in mental health settings with vulnerable patients for about two to three years. After this, she had worked in rapid response rehabilitation within a hospital setting for one to two years. This position had been very different from the rapid response work she had done for Virgin Care. After leaving Virgin Care in December 2020, the Registrant told the Panel that she had done agency work as an occupational therapist and had stopped doing this at around the beginning of 2023, about six months before the substantive hearing.
36. The Registrant confirmed that she would now put into practice all that she had learned from these proceedings: she would obtain contact details from colleagues, she would record detailed and accurate case notes, and she would call an ambulance in an emergency. The Registrant considered that she would be able to put into her practice the transferable skills she had acquired [Redacted]. The Registrant confirmed that the reference in her bundle was from her mentor and friend.
Submissions
37. Ms Khorassani submitted that the Registrant’s fitness to practise remained impaired and that the Suspension Order should be extended. Ms Khorassani reminded the Panel that there was a “persuasive” burden on the Registrant to show that her fitness to practise is no longer impaired on both the personal and the public component.
38. Ms Khorassani submitted that the Panel should consider if the Registrant had fully acknowledged the deficiencies that had led the original panel to find that her fitness to practice was impaired. She submitted that the Registrant had not engaged with the regulatory process until today and had not provided sufficient evidence that she was fit to practise unrestricted. Ms Khorassani referred the Panel to the HCPC’s Standards of Conduct, Performance and Ethics and Standards 6.1, 6.2 and 9.1.
39. Mr Walker submitted that the Registrant’s fitness to practise was no longer impaired. He reminded the Panel that the incident related to one service user and took place on one day when the Registrant failed to exercise clinical judgment correctly and record her attendance accurately. Mr Walker submitted that the misconduct was not at the more serious end of misconduct, even though it had attracted the maximum period of suspension.
40. Mr Walker submitted that the Registrant’s failings were remediable and easily remedied. He submitted that the Registrant had remedied her failings, and it was highly unlikely that she would repeat her misconduct.
41. Mr Walker submitted that the Registrant had gained adequate insight into the impact of her behaviour on the confidence of patients, in the Occupational Therapy profession and in the HCPC as its regulator.
42. Mr Walker submitted that the Registrant had continued to engage with the HCPC. She had attended the review hearing and had obtained representation for that hearing. He submitted that there was no continuing impairment of the Registrant’s fitness to practise, that the Registrant had reflected on the incident over the last year or two and had provided a written reflection. He further submitted that the Registrant had taken on board the concerns of the original panel and sought to address these by reflecting on her behaviour, by undertaking training and considering how best to avoid similar mistakes in the future. Mr Walker submitted that the Registrant understood that standards must be upheld and also understood the impact of her behaviour on her profession and on the HCPC.
43. Mr Walker submitted that the Registrant had been able to say what she had learned from the training she had undertaken in her written reflection and had expanded on this in her oral evidence. [Redacted]. Mr Walker submitted that the Registrant’s level of insight had greatly improved during the period of her suspension and was now at, the very least, an adequate level. He submitted that this meant that the risk of repetition was now low, and that the Registrant’s fitness to practise was not impaired on the personal component.
44. Mr Walker submitted that in relation to the public component, it was in the public interest that competent practitioners were restored to practise as soon as possible when they had achieved appropriate insight and remediation. He submitted that the Registrant had now achieved this and that the Suspension Order should be allowed to expire.
Decision
45. The Panel first considered whether the Registrant’s fitness to practise remained impaired on the personal component. The Panel agreed with Mr Walker that the misconduct in this case was capable of being remedied. It took the view that the Registrant had begun to make good progress towards developing insight into her misconduct. This was, for example, evidenced by her acceptance in evidence of the original Panel’s findings. However, the Panel concluded that the Registrant’s level of insight was not yet adequate to conclude that there was only a low risk of repetition. The Panel considered that the Registrant had yet to fully understand the impact of her behaviour on Service User 1, Service User 1’s family, on her colleagues, her profession and on the wider public interest. The breaches of the HCPC’s Standards of Conduct, Performance and Ethics related to fundamental tenets of her profession. In reaching this conclusion, the Panel was encouraged that the Registrant had engaged with the review hearing despite the late submission of her documentation.
46. The Panel noted that the training undertaken by the Registrant and referred to in her reflective document appeared to be the same courses she had given evidence of at the substantive hearing. There was no evidence before the Panel that she had taken any steps to maintain her skills and knowledge by, for example, undertaking online training in the United Kingdom. The screenshot of an online training course appeared to be from the American Occupational Therapy Association and there were no screenshots of successful completion of the course. The Panel took the view that the various matters which the original panel had suggested might assist this Panel making its decision had not been developed as fully as they should or could have been by the Registrant in her reflections. Her reflections were therefore inadequate to satisfy the Panel that she had taken all appropriate steps to remedy her misconduct. The Panel was satisfied that the Registrant’s fitness to practise remains impaired on the personal component.
47. In relation to the public component, the Panel took the view that whilst the Registrant had made good progress towards developing insight into her misconduct, she had not yet made sufficient progress. In particular, it appeared to the Panel that the Registrant did not fully understand, the impact of her behaviour on her colleagues, her profession or the wider public interest.
48. The Panel was satisfied that a reasonable and well-informed member of the public would expect a finding that the Registrant’s fitness to practise remained impaired, where the Registrant had yet to develop sufficiently good insight into her misconduct and had yet to remedy that misconduct such that there was only a low risk of it being repeated. The Panel was therefore satisfied that the Registrant’s fitness to practise remains impaired on the public component.
49. The Panel considered whether to replace the Suspension Order with a Conditions of Practice Order. The Panel decided that, in light of the progress being made by the Registrant towards remedying her misconduct, and her developing insight, it was possible to devise appropriate and proportionate conditions of practice which would address the concerns it has identified. The Panel is satisfied that the Registrant will comply with conditions of practice.
50. The Panel takes the view that while it cannot bind a future reviewing panel, it might be assisted by the following:
• the attendance of the Registrant at the review hearing;
• documentary evidence of the completion of any Continuing Professional Development undertaken;
• a written reflective piece on the impact of the Registrant’s misconduct on Service User 1, Service User 1’s family, her own colleagues, her profession, and the wider public interest;
• written, dated and signed testimonials/references regarding any employment undertaken by the Registrant.
Order
ORDER: The Suspension Order imposed on 21 July 2023 for a period of 12 months on the registration of Ms Eme S Ufomba is replaced with a Conditions of Practice Order for a period of 12 months.
This Order will come into effect upon expiry of the Suspension Order.
The Conditions of Practice are as follows:
1. You must not undertake employment with any locum agency or work as an independent sole practitioner.
2. You must place yourself and remain under the indirect supervision of a workplace supervisor, registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within 14 days of the Operative Date or the commencement of employment whichever is the later date. You must attend upon that supervisor as required and follow their advice and recommendations including, but not limited to, any further progress with your Personal Development Plan.
3. You must work with your workplace supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:
• Record keeping
• Working collaboratively with colleagues and other healthcare professionals
• Recognising risk
• Clinical reasoning and risk assessment
• Understanding the duty of candour.
4. Within three months of the Operative Date, you must forward a copy of your Personal Development Plan to the HCPC.
5. You must meet with your supervisor on a fortnightly basis to consider your progress towards achieving the aims of your Personal Development Plan.
6. You must allow your supervisor to provide information to the HCPC every three months from the date that you take up employment as an Occupational Therapist about your progress towards achieving the aims set out in your Personal Development Plan.
7. You must inform the HCPC within seven days if you take up employment as an Occupational Therapist and you must inform the HCPC within seven days if you cease employment as an Occupational Therapist.
8. You must inform the HCPC within seven days if you take up any work requiring registration with a professional body outside the United Kingdom.
9. You must inform the HCPC within seven days of returning to practice in the United Kingdom.
10. You must inform the HCPC within seven days of becoming aware of:
A. any patient safety incident you are involved in;
B. any investigation started against you; and
C. any disciplinary proceedings taken against you.
11. You must inform the following parties that your registration is subject to these conditions:
A. any organisation or person employing or contracting with you to undertake professional work;
B. any prospective employer (at the time of your application).
Notes
No notes available
Hearing History
History of Hearings for Eme S Ufomba
| Date | Panel | Hearing type | Outcomes / Status |
|---|---|---|---|
| 18/07/2025 | Conduct and Competence Committee | Review Hearing | Hearing has not yet been held |
| 12/08/2024 | Conduct and Competence Committee | Review Hearing | Conditions of Practice |
| 17/07/2023 | Conduct and Competence Committee | Final Hearing | Suspended |